Healthcare Provider Details

I. General information

NPI: 1497342414
Provider Name (Legal Business Name): FARLAH EXTRA-PHANOR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FARLAH EXTRA

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 NE 138TH ST
NORTH MIAMI FL
33161-3823
US

IV. Provider business mailing address

1031 NE 138TH ST
NORTH MIAMI FL
33161-3823
US

V. Phone/Fax

Practice location:
  • Phone: 305-600-8843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number9500701
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: